HomeMy WebLinkAbout- Septic Pumping Slip - 20 BRIDGES LANE 12/10/2018 Commonwealth of Massachusetts
City/Town of .NORTH ANDOVE.R, TT
System Pumping Record
_._ Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address �,G
to move your North Andover MA 01845
cursor-do not -- - --... _._..._ ____ ..__.._ ____._...
Cit /Town .— -._..
use the return y State Zip Code
key. 2. System Owner:
rae
b _.. 1" ?S
Name
_a_.._
" Address(if different from location)
__.___, __,._ _..�-----
Cityfl`own State Zip Code
Telephone Number
B. Pumping Record —
t
1. Date of Pumping Date 2. Quantity Pumped: Gallons f
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
p/ k
mG'f?
6. System Pumped By:
_ ........_ _.__.P �.-_ _
Name Vehicle Number
Wind River Environmental
Company
7. Location where contents were disposed: 1
Signature of Hauler Date
d
http://www,mass.gov/dep/water/approvals/t5forms.htm#inspect
r
t5form4.doc-06/03 ` a .
Pumping Record•Page 1 of 1